Healthcare Provider Details

I. General information

NPI: 1972677656
Provider Name (Legal Business Name): RIVERWOOD FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3299 CLEAR VISTA CT NE SUITE C
GRAND RAPIDS MI
49525-9477
US

IV. Provider business mailing address

3299 CLEAR VISTA CT NE SUITE C
GRAND RAPIDS MI
49525-9477
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-1200
  • Fax: 616-361-2198
Mailing address:
  • Phone: 616-361-1200
  • Fax: 616-361-2198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL N CLARK
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 616-361-1178